Regulatory Complaints and Fair Hearing Specialist

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Regulatory Complaints & Fair Hearing Specialist will report to the Senior Manager, Fair Hearing & Complaints. The position will assist with the acknowledgement, research, and response to all regulatory complaints (DFS, DOH, BCS, ICAN, AG). The position will be responsible for the collection, tracking, and initial review of all documentation necessary for the construction of the Fair Hearing waiver packets sent to OTDA. The position will assist with complaint and fair hearing data collection and reporting to be presented by the Senior Manager, Fair Hearing & Complaints each quarter to various subcommittees/committees including, but not limited to, the Complaints & Appeals Subcommittee.

• Records, acknowledges, and triages all provider and member complaints and inquiries initiated by regulatory agencies and enters data into company tracking system.
• Works with the Senior Manager to identify the root causes of complaints and fair hearings and works with the applicable operational departments to implement an appropriate resolution - departments include, but are not limited to: Finance, Enrollment, Claims, Provider Relations & Contracting, Member Services, Managed Long Term Care, Medical Management and Utilization Management Appeals.
• Assists the Senior Manager with the communication of complaint resolutions to the requesting agency via written correspondence.
• Assists the Senior Manager with the extraction of complaint and fair hearing data to identify trends and patterns and performs appropriate analysis and translation of data for presentation, by the Senior Manager, during quarterly meetings.
• Drafts comprehensive complaint responses and submits to the Senior Manager for final approval before submission to the requesting agency.
• Receives daily reports from OTDA and handles the initial logging, triage to various business units, and collection of documentation for all fair hearing cases.
• Assists the Senior Manager with the drafting of the waiver summary for some fair hearing cases upon request.
• Maintains all records associated with fair hearings and uploads documentation to the SharePoint tracking system.
• Handles the initial request for documentation sent to internal business units in response to IDR requests and stores all IDR data on appropriate SharePoint tracker.
• Assists the Senior Manager with the tracking of all complaints and fair hearings to ensure adherence to regulatory response timeframes.
• Other tasks as assigned, including but not limited to: printing and mailing of waiver packets; scheduling of internal meetings; organizing fair hearing decision mail; scanning of fair hearing documents.

• Bachelor's degree required
• 5 years' of Managed Care experience; and
• At least 3 of those years working on appeals/fair hearings/grievances; or
• A satisfactory equivalent combination of education, training, and experience
• Knowledge of the New York State (NYS) IDR process is a plus
• Experience managing complicated projects, keeping track of details, and staging work to deliver projects on time
• Proven ability to work interdepartmentally to research complaints, and communicate complex complaint responses, both orally and in writing, in a professional manner
• Demonstrated ability to manage multiple project requests and track review and approval status
• Proficiency in Microsoft Suite (Word, Excel, PowerPoint, SharePoint, and Visio) as well as online/Internet-based research tools

Professional Competencies

• Proficiency in business writing/editing
• Excellent interpersonal skills with a high level of diplomacy and political awareness, and ability to work effectively as a member of the senior management team
• Creative problem-solving abilities
• Critical thinking skills
• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Excellent Written/Oral Communication

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